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Which Treatment Is Best for Urinary Stress Incontinence?

Am Fam Physician. 1999 Jun 1;59(11):3186.

Urinary stress incontinence, a condition characterized by involuntary loss of urine during coughing, sneezing or physical activity, may affect up to one third of women. Incontinence is socially embarrassing, often causing women to avoid social situations and limit regular physical exercise. Various therapies have been recommended, including pelvic floor exercises, surgery, electrical stimulation and use of weighted vaginal cones. However, data comparing the effectiveness of these modalities with no intervention are conflicting and inconclusive. Bo and colleagues evaluated the effectiveness of pelvic floor exercises, electrical stimulation and vaginal cone therapy compared with no treatment in women with stress incontinence.

Women eligible for this randomized controlled trial in Great Britain were either recruited by local advertising or were on a waiting list for surgical treatment. Baseline assessment included a urogynecologic history, uroflowmetry, cystometry, pad test and urinalysis. Inclusion criteria consisted of a history of genuine stress incontinence and more than 4 g of urine leakage on pad testing. Women with significant health problems, including urinary tract infection, were not eligible for the study. After stratification by severity of leakage on pad testing, patients were randomized into three treatment groups and a control group that received no treatment. Patients were taught about the anatomy of the pelvis and lower urinary tract, and were taught how to contract the muscles of the pelvic floor. In addition, patients were told that all treatments were expected to be equally effective, so they should follow only one protocol during the study period. Women in the pelvic muscle training group were asked to perform eight to 12 high-intensity contractions three times daily at home, along with weekly group training sessions with a physical therapist. Women in the electric stimulation group were treated 30 minutes a day following a standardized protocol. Women in the weighted vaginal cones group were asked to retain one of three weights for 20 minutes daily. Follow-up examinations were conducted every month for the six-month study period.

Data were collected on 107 of the 122 women who met the inclusion criteria. Demographic information and clinical findings were similar across groups at baseline. After six months, women in all treatment groups showed some increase in strength of the pelvic floor muscles, whereas women in the control group showed no significant improvement. Those in the muscle training group showed the greatest improvement in muscle strength and the greatest reduction in leakage on the pad test compared with women in the other two treatment groups. In addition, muscle training had no adverse effects, while discomfort and motivation difficulties were reported with the other modalities. At the end of the study, 14 women in the muscle training group, three in the electrical stimulation group, two in the vaginal cones group and one in the control group reported that their symptoms had resolved.

The authors conclude that pelvic floor exercises provided the most effective and acceptable therapy for genuine stress incontinence. They recommend that exercise should be promoted as the first line of therapy for this problem.